Basic Information
| Provider Information | |||||||||
| NPI: | 1447346903 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHEEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 WASHINGTON PL | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031106706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036952500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 WASHINGTON PL | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031106706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036952500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | TP006230D | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 057278-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 30344914 | 05 | NH | MEDICAID |